A nationwide survey of adherence to analgesic drugs among cancer patients in Taiwan: prevalence, determinants, and impact on quality of life

  • Wen-Chi ChouEmail author
  • Jen-Shi Chen
  • Chia-Yen Hung
  • Chang-Hsien Lu
  • Yu-Yun Shao
  • Tzeon-Jye Chiou
  • Yung-Chuan Sung
  • Kun-Ming Rau
  • Chia-Jui Yen
  • Su-Peng Yeh
  • Ta-Chih Liu
  • Ming-Fang Wu
  • Ming-Yang Lee
  • Ming-Sun Yu
  • Wen-Li Hwang
  • Pang-Yu Lai
  • Cheng-Shyong Chang
  • Ruey-Kuen Hsieh
Original Article



Poor adherence to analgesic drugs is one of the most common barriers to adequate pain management. This prospective, cross-sectional, patient-oriented observational study aimed to explore the adherence rate, clinical factors, and impact of adherence to analgesic drugs on the quality of life (QoL) among cancer outpatients in Taiwan.


Eight hundred ninety-seven consecutive adult outpatients with cancer who had reported tumor pain and received regular analgesic drug treatment were enrolled from 16 medical centers across Taiwan. The Brief Pain Inventory was used to assess pain intensity and QoL. Morisky’s four-item medication adherence scale was used to assess adherence to analgesic drugs. Clinical factors possibly associated with good adherence to analgesic drugs were analyzed using multivariate logistic regression analyses.


Of the 897 patients, 26.9% met criteria for the good, 35.5% for the moderate, and 37.6% for the poor adherence groups. The good adherence group had significantly better QoL outcomes than the moderate and poor adherence groups (all p < 0.05). Age ≥ 50 years, head and neck or hematological malignancies, cancer-related pain, patients who agreed or strongly agreed that the side effects of analgesic drugs were tolerable, and patients who disagreed or strongly disagreed that the dosing schedule could be flexibly self-adjusted to deal with the actual pain were predictors of good adherence to analgesic drugs.


Awareness of the clinical factors associated with adherence to analgesic drugs may help clinicians to identify cancer patients at a greater risk of non-adherence, reinforce optimal pain management, and improve the QoL by enhancing adherence to pain medications.


Cancer Pain Adherence Predictive factor Quality of life 


Compliance with ethical standards


The authors gratefully acknowledge the assistance of the patients who participated in this study, and support grants from the Taiwan Society of Cancer Palliative Medicine and Johnson & Johnson.

Conflicts of interest

The authors declare that they have no competing interests.

Supplementary material

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Supplementary Table 1 (DOCX 14 kb)
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Supplementary Table 2 (DOCX 13 kb)
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Supplementary Table 3 (DOCX 14 kb)


  1. 1.
    van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J (2007) High prevalence of pain in patients with cancer in a large population-based study in The Netherlands. Pain 132(3):312–320PubMedCrossRefGoogle Scholar
  2. 2.
    van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J (2007) Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol 18(9):1437–1449PubMedCrossRefGoogle Scholar
  3. 3.
    Teunissen SC, Wesker W, Kruitwagen C, de Haes HC, Voest EE, de Graeff A (2007) Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manag 34(1):94–104CrossRefGoogle Scholar
  4. 4.
    Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, Cherny N, Dale O, de Conno F, Fallon M, Hanna M, Haugen DF, Juhl G, King S, Klepstad P, Laugsand EA, Maltoni M, Mercadante S, Nabal M, Pigni A, Radbruch L, Reid C, Sjogren P, Stone PC, Tassinari D, Zeppetella G (2012) Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol 13(2):e58–e68PubMedCrossRefGoogle Scholar
  5. 5.
    Ripamonti CI, Bandieri E, Roila F, ESMO Guidelines Working Group (2011) Management of cancer pain: ESMO clinical practice guidelines. In: Ann Oncol 22 Suppl 6:vi69–77Google Scholar
  6. 6.
    Greco MT, Roberto A, Corli O, Deandrea S, Bandieri E, Cavuto S, Apolone G (2014) Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer. J Clin Oncol 32(36):4149–4154PubMedCrossRefGoogle Scholar
  7. 7.
    Deandrea S, Montanari M, Moja L, Apolone G (2008) Prevalence of under-treatment in cancer pain. A review of published literature. Ann Oncol 19(12):1985–1991PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    National Health Research Institutes and Taiwan Cooperative Oncology Group. Clinical guideline for management of cancer pain, 1st ed (2007). Miaoli County, Taiwan. Available at: Accessed 01 February 2018
  9. 9.
    Hsieh RK (2005) Pain control in Taiwanese patients with cancer: a multicenter, patient-oriented survey. J Formos Med Assoc 104(12):913–919PubMedGoogle Scholar
  10. 10.
    Rau KM, Chen JS, Wu HB, Lin SF, Lai MK, Chow JM, Huang ML, Wang CJ, Tai CJ, Hwang WL, Lu YC, Chan CH, Hsieh RK (2015) The impact of pain control on physical and psychiatric functions of cancer patients: a nation-wide survey in Taiwan. Jpn J Clin Oncol 45(11):1042–1049PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Shen WC, Chen JS, Shao YY, Lee KD, Chiou TJ, Sung YC, Rau KM, Yen CJ, Liao YM, Liu TC, Wu MF, Lee MY, Yu MS, Hwang WL, Lai PY, Chang CS, Chou WC, Hsieh RK (2017) Impact of undertreatment of cancer pain with analgesic drugs on patient outcomes: a nationwide survey of outpatient cancer patient care in Taiwan. J Pain Symptom Manag 54(1):55–65CrossRefGoogle Scholar
  12. 12.
    Meuser T, Pietruck C, Radbruch L, Stute P, Lehmann KA, Grond S (2001) Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain 93(3):247–257PubMedCrossRefGoogle Scholar
  13. 13.
    Jamison RN, Sheehan KA, Scanlan E, Matthews M, Ross EL (2014) Beliefs and attitudes about opioid prescribing and chronic pain management: survey of primary care providers. J Opioid Manag 10(6):375–382PubMedCrossRefGoogle Scholar
  14. 14.
    Potter VT, Wiseman CE, Dunn SM, Boyle FM (2003) Patient barriers to optimal cancer pain control. Psychooncology 12(2):153–160PubMedCrossRefGoogle Scholar
  15. 15.
    Liang SY, Yates P, Edwards H, Tsay SL (2008) Factors influencing opioid-taking self-efficacy and analgesic adherence in Taiwanese outpatients with cancer. Psychooncology 17(11):1100–1107PubMedCrossRefGoogle Scholar
  16. 16.
    Lin CC (2000) Barriers to the analgesic management of cancer pain: a comparison of attitudes of Taiwanese patients and their family caregivers. Pain 88(1):7–14PubMedCrossRefGoogle Scholar
  17. 17.
    Gunnarsdottir S, Donovan HS, Serlin RC, Voge C, Ward S (2002) Patient-related barriers to pain management: the Barriers Questionnaire II (BQ-II). Pain 99(3):385–396PubMedCrossRefGoogle Scholar
  18. 18.
    Lee BO, Liu Y, Wang YH, Hsu HT, Chen CL, Chou PL, Hsu WC (2015) Mediating effect of family caregivers’ hesitancy to use analgesics on homecare cancer patients' analgesic adherence. J Pain Symptom Manag 50(6):814–821CrossRefGoogle Scholar
  19. 19.
    Corli O, Montanari M, Deandrea S, Greco MT, Villani W, Apolone G (2012) An exploratory analysis on the effectiveness of four strong opioids in patients with cancer pain. Pain Med 13(7):897–907PubMedCrossRefGoogle Scholar
  20. 20.
    Miaskowski C, Dodd MJ, West C, Paul SM, Tripathy D, Koo P, Schumacher K (2001) Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. J Clin Oncol 19(23):4275–4279PubMedCrossRefGoogle Scholar
  21. 21.
    Valeberg BT, Miaskowski C, Hanestad BR, Bjordal K, Moum T, Rustoen T (2008) Prevalence rates for and predictors of self-reported adherence of oncology outpatients with analgesic medications. Clin J Pain 24(7):627–636PubMedCrossRefGoogle Scholar
  22. 22.
    Graziottin A, Gardner-Nix J, Stumpf M, Berliner MN (2011) Opioids: how to improve compliance and adherence. Pain Pract 11(6):574–581PubMedCrossRefGoogle Scholar
  23. 23.
    Daut RL, Cleeland CS, Flanery RC (1983) Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Pain 17(2):197–210PubMedCrossRefGoogle Scholar
  24. 24.
    Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA, Pandya KJ (1994) Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 330(9):592–596PubMedCrossRefGoogle Scholar
  25. 25.
    Morisky DE, Green LW, Levine DM (1986) Concurrent and predictive validity of a self- reported measure of medication adherence. Med Care 24(1):67–74PubMedCrossRefGoogle Scholar
  26. 26.
    Tzeng JI, Chang CC, Chang HJ, Lin CC (2008) Assessing analgesic regimen adherence with the Morisky Medication Adherence Measure for Taiwanese patients with cancer pain. J Pain Symptom Manag 36(2):157–166CrossRefGoogle Scholar
  27. 27.
    Schmid H, Hartmann B, Schiffl H (2009) Adherence to prescribed oral medication in adult patients undergoing chronic hemodialysis: a critical review of the literature. Eur J Med Res 14(5):185–190PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    McHorney CA (2009) The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease. Curr Med Res Opin 25(1):215–238PubMedCrossRefGoogle Scholar
  29. 29.
    Zhang H, Singer B (1999) Recursive partitioning in the health sciences. In: Analysis of censored data: survival trees. Springer, New York, pp 93–104Google Scholar
  30. 30.
    Osterberg L, Blaschke T (2005) Adherence to medication. N Engl J Med 353(5):487–497PubMedCrossRefGoogle Scholar
  31. 31.
    Meghani SH, Thompson AM, Chittams J, Bruner DW, Riegel B (2015) Adherence to analgesics for cancer pain: a comparative study of African Americans and Whites using an electronic monitoring device. J Pain 16(9):825–835PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Ogrodniczuk JS, Piper WE, Joyce AS (2006) Treatment compliance in different types of group psychotherapy: exploring the effect of age. J Nerv Ment Dis 194(4):287–293PubMedCrossRefGoogle Scholar
  33. 33.
    Ktsanas D, Al-Souffi MH, Waxman BP, King RW, Polkinghorne KR, Woolley IJ (2006) Adherence to guidelines for prevention of postsplenectomy sepsis. Age and sex are risk factors: a five-year retrospective review. ANZ J Surg 76(7):542–547CrossRefGoogle Scholar
  34. 34.
    Ward SE, Golberg N, Miller-McCauley V et al (1993) Patient-related barriers to management of cancer pain. Pain 52(3):319–324PubMedCrossRefGoogle Scholar
  35. 35.
    Cohen HW, Shmukler C, Ullman R, Rivera CM, Walker EA (2010) Measurements of medication adherence in diabetic patients with poorly controlled HbA(1c). Diabet Med 27(2):210–216PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Wen-Chi Chou
    • 1
    Email author
  • Jen-Shi Chen
    • 1
  • Chia-Yen Hung
    • 1
    • 2
  • Chang-Hsien Lu
    • 3
  • Yu-Yun Shao
    • 4
  • Tzeon-Jye Chiou
    • 5
  • Yung-Chuan Sung
    • 6
  • Kun-Ming Rau
    • 7
  • Chia-Jui Yen
    • 8
  • Su-Peng Yeh
    • 9
  • Ta-Chih Liu
    • 10
  • Ming-Fang Wu
    • 11
  • Ming-Yang Lee
    • 12
  • Ming-Sun Yu
    • 13
  • Wen-Li Hwang
    • 14
  • Pang-Yu Lai
    • 15
  • Cheng-Shyong Chang
    • 16
  • Ruey-Kuen Hsieh
    • 2
  1. 1.Division of Hematology-Oncology, Department of Internal Medicine, Linkuo Chang Gung Memorial Hospital and College of MedicineChang Gung UniversityTaoyuan CountyTaiwan
  2. 2.Division of Hematology-Oncology, Department of Internal MedicineMackay Memorial HospitalTaipeiTaiwan
  3. 3.Division of Hematology-Oncology, Department of Internal MedicineChiayi Chang Gung Memorial HospitalChiayiTaiwan
  4. 4.Department of OncologyNational Taiwan University HospitalTaipeiTaiwan
  5. 5.Division of Hematology-OncologyTaipei Veterans General HospitalTaipeiTaiwan
  6. 6.Division of Hematology-OncologyCathay General HospitalTaipeiTaiwan
  7. 7.Division of Hematology-Oncology, Department of Internal MedicineKaohsiung Chang Gung Memorial HospitalKaohsiungTaiwan
  8. 8.Division of Hematology-OncologyNational Cheng Kung University HospitalTainanTaiwan
  9. 9.Division of Hematology-OncologyChina Medical University HospitalTaichungTaiwan
  10. 10.Division of Hematology-OncologyKaohsiung Medical University Chung-Ho Memorial HospitalKaohsiungTaiwan
  11. 11.Divisions of Medical Oncology and Chest Medicine, Chung Shan Medical University Hospital, School of MedicineChung Shan Medical UniversityTaichungTaiwan
  12. 12.Division of Hematology-OncologyDitmanson Medical Foundation Chiayi Christian HospitalChiayiTaiwan
  13. 13.Division of Hematology-OncologyKaohsiung Veterans General HospitalKaohsiungTaiwan
  14. 14.Division of Hematology-OncologyTaichung Veterans General HospitalTaichungTaiwan
  15. 15.Division of Hematology-OncologyE-DA HospitalKaohsiungTaiwan
  16. 16.Division of Hematology-OncologyChanghua Christian HospitalChanghuaTaiwan

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